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SPATIAL  DISORIENTATION

Number of accidents have occurred around the world due to Spatial Disorientation.

Tests conducted with qualified instrument pilots indicate that it can take as much as 35 seconds to establish full control by instruments after the loss of visual reference with the surface.

Five most common illusions reported were:

60 percent had a sensation that one wing was low although wings were level.

45 percent had, on levelling after banking, tended to bank in opposite direction.

39 percent had felt as if straight and level when in a turn.

34 percent had become confused in attempting to mix “Contact” and instrument cues.

29 percent had, after recovery from steep climbing turn, felt to be turning in opposite direction,

Surface references and the natural horizon may at times become obscured, although visibility may be above visual flight rule minimums.

Lack of natural horizon or surface reference is common on overwater flights, at night, and especially at night in extremely sparsely populated areas, or in low visibility conditions.

A sloping cloud formation.

An obscured horizon.

A “White-out” condition caused by fog, haze, or falling snow blending with the snow-covered earth surface.

A dark scene spread with ground lights and stars.

And certain geometric patterns of ground lights can provide inaccurate visual information for aligning the aircraft correctly with the actual horizon.

Other factors which contribute to disorientation are:

Reflections from outside lights.

Sunlight shining through clouds.

Reflected light from the anti-collision rotating beacon, Flashing Lights, Nav Lights and Rotor Tip Lights.

All these factors may obscure outside references leading to a disoriented pilot who may place the aircraft in a dangerous attitude as a consequence of sensory illusions.

VESTIBULAR ASPECTS OF SPATIAL ORIENTATION:

The inner ear contains the vestibular system, which is also known as the organ of equilibrium.

About the size of a pencil eraser, the vestibular system contains two distinct structures:

The semi-circular canals, which detect changes in angular acceleration.

And the otolith organs (the utricle and the saccule), which detect changes in linear acceleration and gravity.

Both the semi-circular canals and the otolith organs provide information to the brain regarding our body’s position and movement.

A connection between the vestibular system and the eyes helps to maintain balance and keep the eyes focused on an object while the head is moving or while the body is rotating.

THE SEMICIRCULAR CANALS.

The semi-circular canals are three half-circular, interconnected tubes located inside each ear that are the equivalent of three gyroscopes located in three planes perpendicular (at right angles) to each other.

Each plane corresponds to the rolling, pitching, or yawing motions of an aircraft.

Each canal is filled with a fluid called endolymph and contains a motion sensor with little hairs whose ends are embedded in a gelatinous structure called the cupula.

The cupula and the hairs move as the fluid moves inside the canal in response to an angular acceleration.

The movement of the hairs is similar to the movement of seaweed caused by ocean currents or that of wheat fields moved by wind gusts.

When the head is still and the airplane is straight and level, the fluid in the canals does not move and the hairs stand straight up, indicating to the brain that there is no rotational acceleration (a turn).

If you turn either your aircraft or your head, the canal moves with your head, but the fluid inside does not move because of its inertia.

As the canal moves, the hairs inside also move with it and are bent in the opposite direction of the acceleration by the stationary fluid.

This hair movement sends a signal to the brain to indicate that the head has turned.

The problem starts when you continue turning your aircraft at a constant rate (as in a coordinated turn) for more than 20 seconds.

In this kind of turn, the fluid inside the canal starts moving initially, and then friction causes it to catch up with the walls of the rotating canal.

When this happens, the hairs inside the canal will return to their straight up position, sending an erroneous signal to the brain that the turn has stopped– when, in fact, the turn continues.

If you then start rolling out of the turn to go back to level flight, the fluid inside the canal will continue to move (because of its inertia), and the hairs will now move in the opposite direction .

Sending an erroneous signal to the brain indicating that you are turning in the opposite direction, when in fact, you are actually slowing down from the original turn.

VESTIBULAR ILLUSIONS (SOMATOGYRAL – Semi-circular Canals)

Illusions involving the semi-circular canals of the vestibular system occur primarily under conditions of unreliable or unavailable external visual references and result in false sensations of rotation.

These include the:

Leans.

The Graveyard Spin and Spiral.

The Coriolis Illusion.

The Leans is the most common illusion during flight and is caused by a sudden return to level flight following a gradual and prolonged turn that went unnoticed by the pilot.

The reason a pilot can be unaware of such a gradual turn is that human exposure to a rotational acceleration of 2 degrees per second or lower is below the detection threshold of the semi-circular canals.

Levelling the wings after such a turn may cause an illusion that the aircraft is banking in the opposite direction.

In response to such an illusion, a pilot may lean in the direction of the original turn in a corrective attempt to regain the perception of a correct vertical posture.

The Graveyard Spiral is more common than the Graveyard Spin, and it is associated with a return to level flight following an intentional or unintentional prolonged bank turn.

For example, a pilot who enters a banking turn to the left will initially have a sensation of a turn in the same direction. If the left turn continues (~20 seconds or more), the pilot will experience the sensation that the airplane is no longer turning to the left.

At this point, if the pilot attempts to level the wings this action will produce a sensation that the airplane is turning and banking in the opposite direction (to the right).

If the pilot believes the illusion of a right turn (which can be very compelling), he/she will re-enter the original left turn in an attempt to counteract the sensation of a right turn.

Unfortunately, while this is happening, the airplane is still turning to the left and losing altitude.

Pulling the control yoke/stick and applying power while turning would not be a good idea–because it would only make the left turn tighter.

If the pilot fails to recognize the illusion and does not level the wings, the airplane will continue turning left and losing altitude until it impacts the ground.

The Coriolis Illusion involves the simultaneous stimulation of two semi-circular canals and is associated with a sudden tilting (forward or backwards) of the pilot’s head while the aircraft is turning.

This can occur when you tilt you head down (to look at an approach chart or to write a note on your knee pad).

Or tilt it up (to look at an overhead instrument or switch) or tilt it sideways.

This produces an almost unbearable sensation that the aircraft is rolling, pitching, and yawing all at the same time, which can be compared with the sensation of rolling down on a hillside.

This illusion can make the pilot quickly become disoriented and lose control of the aircraft.

Non-adherence to standard operating procedures (SOPs).

The captain, as PF, did not follow standard procedures, resulting in:

A higher than standard speed for start of descent and initial approach.

A non-stabilized approach.

The low-altitude orbit as a nonstandard manoeuvre to the runway.

The incorrectly performed go-around.

The first officer did not object or call the captain’s attention to his non adherence to the procedure.

The controller allowed a shortcut — a 360-degree turn above the airport — and did not follow the procedure for the path leading to a stabilized approach from the final fix.

During go-around, the crew apparently experienced spatial disorientation, which may have caused the captain to wrongly think the airplane was pitching up.

Despite the GPWS warnings, the crew did not adequately respond.

Analysis of the cockpit voice recorder (CVR) data showed the crew did not perform as a team, due to inadequate training in crew resource management (CRM), SOPs, controlled flight into terrain (CFIT) and GPWS.

Somatogyral/ Somatogravic illusions.

During the approach in night conditions, the crew had on one side a very bright view of the airport and a landmass and on the other side a completely dark area over the water.

Focusing on the visual approach, the crew may have lost visual cues and may have experienced visual illusions and disorientation when initiating the tight 360- degree turn over water, after the non-stabilized approach.

The first officer, as pilot not flying (PNF), was not monitoring his instruments and did not use proper CRM techniques to gain the captain’s attention.

In addition, TOGA provides constant acceleration.

In the absence of visual cues such as the horizon, this constant longitudinal acceleration fooled the captain’s vestibular system into interpreting this as horizontal flight at constant speed.

Prevention Strategies.

Lines of Defence.

The first precaution to avoid an accident is to not put oneself in a nonstandard situation.

The resulting situation may not appear to be risky at the beginning, but, as we know, accidents often result from multiple contributing factors.

Allowing the situation to develop in the first place generates unnecessary risks.

Further, the quality of the approach briefing helps to focus on the following:

Ensuring that one crewmember maintains visual contact with the runway lights.

Task sharing and workload management between the crewmembers.

Effective coordination with the ATC.

Being prepared for a go-around.

Remembering the consequences of visual illusions when there is a mismatch between the real world and what is sensed.

Maintaining continuous instrument monitoring to counter the onset of vestibular system illusions.

When realizing that situational awareness is lost:

Applying strict SOPs such as precise go-around procedures with task sharing.

Callouts.

Go-around altitudes.

Speeds, headings and minimum safe altitudes.

This is the principal reason for approved SOPs.

Adherence to SOPs.

Adequate CRM training helps to achieve an effective balance among crewmembers.

Emphasis on cross-checking and clear task sharing provides a basis for sound attitudes.

In our example, the first officer’s task was to monitor the instruments to effectively and adequately inform his captain.

The captain’s role in relation to his first officer was to encourage him to speak.

Quality of briefings:

Operational procedures require a go-around to be flown at constant speed and without any acceleration with one flap retraction.

The acceleration and clean up should be done at a higher altitude.

This is to ensure that a correct go-around is performed and associated procedures follow.

In general, there are no go-around procedures that require a sustained turn because, from a human factors point of view, crews might suffer Somatogyral (Coriolis) disorientation as well as Somatogravic (false climb) disorientation.

Avoiding shortcuts and strict adherence to procedures help to avoid creating risky situations.

Improved training in CRM and visual illusions.

Training to prevent Somatogravic illusion is almost impossible, but information and sensitization can help pilots recognize its onset and prepare to face it.

The only known way to regain proper orientation is to focus on the airplane’s instruments to rebuild a correct mental image of the situation.

The pilot should understand the elements contributing to spatial disorientation so as to prevent loss of aircraft control if these conditions are inadvertently encountered.

The following are certain basic steps which should assist materially in preventing spatial disorientation.

Before flying in less than 5 Kms visibility, obtain training and maintain proficiency in airplane control by reference to instruments.

When flying at night or in reduced visibility, use the flight instruments.

If intending to fly at night, maintain night-flight currency. Include cross country and local operations at different airports.

If only Visual Flight Rules-qualified, do not attempt visual flight when there is a possibility of getting trapped in deteriorating weather.

If you experience a vestibular illusion during flight, trust your instruments and disregard your sensory perceptions.

Study and become familiar with unique geographical conditions in areas proposing to operate.

Check weather forecasts before departure, en route, and at destination.

Be alert for weather deterioration.

Do not attempt visual flight rule flight when there is a possibility of encountering deteriorating weather.

Discipline helps: adherence to SOPs helps improve safety.

In the absence of visual cues, referring to the instruments to get a correct mental image and continuous instrument monitoring may help to counter vestibular disorientation.

Rely on instrument indications unless the natural horizon or surface reference is clearly visible.

Adequate crew communication is a critical contributing factor to risk reduction as well as effective coordination with ATC.

Remain prepared for a go-around while remaining aware of possible visual illusions.

 

 

 

 

Controlled Flight into Terrain (CFIT)

When an airworthy aircraft or helicopter under the command of a qualified pilot is inadvertently or without prior knowledge is flown into terrain, water or obstructions, is called CFIT. Most of the CFIT accidents are fatal and almost always a pilot error.

 CFIT mostly occurs when visual cues are lost due to flying during night or into clouds, fog or poor visibility conditions. Under such conditions, Pilots may get spatially disorientated, loose Situational Awareness and meets with CFIT accidents. In addition visual illusions, also add to the CFIT accident statistics.
CFIT is more likely to occur over water, hilly areas, long stretches of forested or desert terrain and Night due to lack of prominent visual cues.

Most of the CFIT accidents occur during final approach and landing or during take-off and initial climb. However, Number of Aircraft/Helicopter accidents have occurred during cruise or manoeuvring flight.

Causes of CFIT

Lack of:-

• Proper Flight Planning, Preparations.
• Adequate weather briefing, knowledge and intelligent monitoring of weather.
• Proper analysis of terrain with particular emphasis on Minimum Enroute Altitude, Minimum Safe or Sector Altitude, Minimum off route altitude (MORA),Grid MORA, Minimum Descent Altitude, obstructions around runways, helipads, towers, pylons, power, Cable Car/ trolley cables particularly in the mountains.
• Knowledge about SOP’s, Check List, Procedures, Approach, Enroute, Let down Charts , Weather Radar, GPS, Flight Management System, Automatic Flight Control System, Automation, Electronic Flight Instrumentation System, ILS, VOR,EGPWS,DME.
• Knowledge about Spatial Disorientation, Visual Illusions.
• Situational Awareness- Horizontal, Vertical and overall.
• Correct Altimeter Settings and Cross Check between PF and PM.
• Adequate CRM and Proper Communication.
• Compliance with SOP’s, Rules, Regulations.

Lack of proper configuration and verification of the flight management computer for the profile approach.

Inadequate Vertical Mode Selections of the Aircraft Flight Control System (AFCS).

Inadequate or delayed response to the Warning Alerts of EGPWS/Terrain Awareness and Warning System.

Inadequate or delayed Missed Approach and Go around Flight Path.

Lateral and/or vertical deviation from intended flight path.

Loss of terrain separation.

Low Energy State during Approach / Unstable Approach.

Inadequate Response to Wind Sheer Warning.

Continued approach, when below DA (H) or MDA (H), after loss of visual references.

Unstable approach and Failure to Go Around in time.

Late or inadequate response to MSAW warning.

Lack of effective flight path control during go-around.

Failure to follow published missed-approach procedure.

Inadequate fuel management.

Fatigue and Stress.

Interruptions / Distractions.

Overconfidence, Complacency, Macho Attitude.

VIP, Commercial, Peer and Self Imposed Pressures.

Lack of effective and result oriented Simulator Training, Flight and Ground Training, CRM, All Weather Operations.

Inadequate supervision, lack of monitoring by the Senior Management and Accountable Managers.

Hazardous Attitudes like Ante Authority, Invulnerability, Impulsiveness, Macho and Resignation.

Lack of currency in hands on flying, instrument flying.

Lack of communication, Proper Pre Flight Briefing, Pre Descent, Approach Briefing and Debriefing.

Lack of teamwork and synergy.

Distraction/ loss of Attention.

Poorly developed and outdated Procedures, SOP’s.

Poor Decision Making, Delayed Decision, Fixation, Distraction.

Not knowing or not following the Golden Rule in Aviation which is Aviate-Navigate-Communicate.

Human performance limitations and deficiencies.

Cockpit Gradient/Authority Gradient/Power Distance which takes away the ability of the Co Pilot or First Officer to Speak up or correct the Captain when he is doing something wrong. Lack of assertiveness by the Co Pilot or First Officer.

Single Pilot aircraft or Helicopters are more susceptible to CFIT.

Duck under Syndrome or Scud Running.

Flying visually in IMC conditions or mixing instrument flying and visual flying.

Exceeding the laid down limitations.

Misunderstanding or misinterpretation of ATC instructions or blindly following ATC instructions.

Automated “MINIMUM” alert not activated. 

Inadequate response to the EGPWS alert.

EGPWS software was not updated.

Stabilized criteria is not respected.

Failed to monitor the aircraft’s altitude during the approach.

The relevant weather was not provided to the flight crew.

Delayed decision to execute missed approach when unstable approach or unable to see visual reference below MDA(H).

For helicopter pilots, reluctance to land at suitable place if unable to continue flight due weather.

 

Prevention of CFIT Accidents.

Planning, preparation for the flight needs to be thorough.

Obtain proper Met Briefing, forecast and interpret the weather to see how it will impact on your Flight.

Be knowledgeable about the hazards of flying during pre-monsoon (Norwesters or Kal Baisakhi), Monsoons, Foggy   Winter Months, Wind Shear, Western Disturbances, Cyclones, Tsunami etc.

Improve your knowledge about the weather and how to interpret the weather from the various websites like IMD, Acu Weather, Sky Met and Meteo Earth Etc.

Make good use of the information available from METARS, ATIS, about the weather, runway conditions and act accordingly in time. Respect the Weather and do not press on in adverse weather.

ATC, Met and Company dispatch, must ensure that updated weather information are provided to the Pilots.

Thorough knowledge of Terrain, highest obstructions, Minimum Enroute altitude, Minimum Sector or Safe Altitude, Minimum Off route Altitude, obstructions in the approach path to the Runway or the Helipad and obstructions around the Airport, Helipads. Hilly reason may have Chair Car trolley cables or power cables, communication cables, transmission towers. Knowledge of these and good look out while flying in the hills particularly for helicopter pilots who fly along the valleys at low levels.

Captain, Co Pilot or First Officer should be having good knowledge about the Aircraft, Helicopter, its systems, Avionics, Nav Aids, approach and let down charts, Jepson charts, Weather Radar, Flight Management System, Automatic Flight Control System, SOP’s, Rules, Regulations, Spatial disorientation, Visual Illusions, Situational awareness, recovery from unusual attitudes, recovery from wind shear, stable approach, missed approach procedure, Take off and Go Around Mode switch, SIDS and STAR’s, ILS, Non Precision CDFA approaches.

Carry our proper risk assessment of the flight in coordination with the other crew, taking all the factors into consideration and decide on minimums for the flight which should be respected.

Undertake comprehensive pre-flight, pre decent and Approach briefing of the crew covering the aspects about weather, terrain, obstructions, type of approach, runway condition, winds and division of duties and responsibilities between Captain and Co Pilot or First Officer.

Follow the SOP meticulously. If you feel that SOP is not properly drafted and may compromise safety, it should be reviewed, updated and approved.

Always keep in mind the Golden Rule in Aviation-Aviate-Navigate-Communicate and make sure that at least one Pilot is flying all the time.

Beware of overconfidence, complacency, distraction, Fixation, lack of attention which may lead to loss of situational awareness.

Be Situationally Aware particularly Horizontal and Vertical situational awareness at all times.

Know your capabilities and limitations.

Be very careful in entering data into computers, FMS, AFCS, GPS etc  and selection of correct frequencies must be ensured and cross checked.

Correct Altimeter setting must be entered and ensure cross check and call outs between Captain and Co Pilot and with radio Altimeter. Knowledge of the altitudes for changing from QNH to QNE and vice versa is essential.

Remain current with hands on flying, instrument flying and be knowledgeable to recover from unusual attitudes, wind shear.

Take timely decision to execute missed approach and diversion. No questions will be asked by DGCA, ATC or Operator if pilots execute missed approach or divert due unstable approach or weather conditions (DGCA CAR on ALL Weather Operations).

Helicopter pilots should not hesitate to land at a suitable place if unable to continue the flight due weather (DGCA, ASC 09/2013).

Do not descend in IMC conditions or under cast conditions unless sure of the terrain or following established procedures under radar surveillance.

Do not carry out spiral descent or descend through hole since it may lead to special disorientation. Descend in a race course pattern if required.

Do not succumb to commercial, on time performance, VIP, passenger, peer or self-imposed pressures to undertake flight in the face of adverse weather conditions. Always take a professional well considered decision.

Get Homitis, get thereitis and mind set should be kept under check and no chances should be taken with the safety of the aircraft, crew and passengers.

Do not follow ATC instructions blindly and be situationally aware. If the ATC gives you a radial to fly which is taking you into weather, tell ATC unable and ask for another radial. If ATC gives you altitude to climb or decent which may put you in conflict with other traffic or with your minimum safe altitude, advise the ATC accordingly. Listen out the ATC instructions carefully and don’t hesitate to verify if in doubt.

Keep open atmosphere in the cockpit where crew members are free to give inputs, particularly related to safety of the aircraft/helicopter without any hesitation, fear, apprehension, snubbing or reprisals.

The Co Pilot/First Officer should be given freedom to be assertive and encouraged by Captain to correct or caution the Captain and even take over control if the Captain continues the approach in spite of the approach being unstable or without sighting the runway or any of the runway clues at MDA (H).

Do not undertake the Flight if you are stressed, fatigued or unwell. Be very careful while taking flight during Window of Circadian Low and be aware of Human Performance Limitations.

No decision should be taken if it is influenced by hazardous attitudes like Ante Authority, Impulsivity, Invulnerability, Macho or Resignation.

Operators and Pilots also must ensure to conduct a proper pre-flight planning session and familiarize themselves with the terrain that may surround them during their flight, as terrain familiarization is critical to safe visual operations, in particular at night

CDFA techniques contribute to a stabilized approach. Hence, the operators should develop procedures and train pilots to fly a stabilized CDFA.

Effective crew coordination and crew performance, and in general CRM principles and behaviours can reduce pilots’ workload and decrease the probability of human errors.

Enhancing pilot performance and complacency, both in normal and abnormal circumstances, will empower pilots to intervene, with greater confidence and competence, to prevent any environmental threats and hazards that could lead to high-risk outcomes.  Operators must ensure that their training programs robustly address potential deficiencies, environmental, technical/non-technical factors such as human factors, air carrier’s SOPs.

Encourage operators to review their procedures for responding to alerts on final approach to ensure that these procedures are sufficient to enable pilots to avoid impact with terrain or obstacles in such situations.

Operators should always ensure that their EGPWS software is update to date.

Pilots’ knowledge of aircraft systems, aircraft performance and normal/abnormal procedures is vital to ensure that they do not find themselves in unexpected situations from which they cannot immediately recover.

Pilots must also be keenly aware of the risks of CFIT, the circumstances in which those risks are greatest and the best strategies for maintaining an accurate picture of their horizontal and vertical situation.

Pilots’ competence in recognizing and responding to potential CFIT must be realistically trained and tested in recurrent simulator training sessions, using examples from operational experience.

Analysis of the causes of CFIT accidents should be included in the training courses to help pilots to understand their own limitations and recognize when an undesirable situation is developing.

Learn an escape manoeuvre and techniques designed to enhance the possibility of survival.

Improved monitoring and cross-checking are methods that can prevent many of the accidents

Good CRM behaviour and Pilot Monitoring can help to mitigate CFIT accidents.

Operational procedures can also provide CFIT risk mitigations by avoiding non-precision approaches especially in high risk destinations or adopting risk reducing strategies such as CDFA or PBN approaches.

Pilot in command should be aware of the risks involved when transitioning from visual to instrument or from instrument to visual procedures on take-off or landing.

Helicopter pilots are more likely to get into CFIT conditions since they fly at low levels in hostile terrain. In addition to adverse weather conditions, environmental factors such as time of day, minimal light, shadows, darkness, sun glare, cockpit blind spots, fatigue, or other such factors may result in the pilot losing situational awareness and hitting an obstacle or impacting the ground.

Even if a Pilot is aware of the obstructions and environmental factors, He/She may not be able to see the danger in time or may see the danger but fail to react in time to avoid collision.

Flying in the hills along the valleys can result in a CFIT accident if a power line or cable is strung between the hills. Flying up a box canyon and not being able to fly up and out of it before impacting terrain. Flying over rising terrain that exceeds an aircraft’s/helicopters ability or performance to climb away from the terrain.

Pilots should be aware about the adverse effects of high density altitude which may lead to low reserve of power with consequent large radius of turn, at high altitudes. Under such conditions, manoeuvring the helicopter in narrow valleys may lead to collision with terrain.

Helicopter pilots, particularly, must be fully prepared, knowledgeable about the weather, environmental factors, terrain, obstructions, and adverse effects of high density altitude on performance, performance limitation of the helicopter, disorientation, snow blindness, icing and strong vertical and horizontal wind shear etc. Remember mountain flying in adverse weather conditions is a deadly situation.

Never take chances with weather particularly in the hills, high seas and night.

 

Analysis of number of accidents/serious incidents have highlighted following issues related to safety and for prevention of CFIT accidents.

Situational Awareness has been found deficient in number of accidents analysed. It is recommended that operators increase training on maintaining situational awareness at all times, especially when close to the ground, and provide pilots with appropriate language and procedures to communicate, and respond to, positional concerns without delay.

Procedural non-compliance is a common factor in CFIT accidents. It is recommended that operators promote and enforce a culture of universal compliance with policies and procedures, unless unusual circumstances directly affecting safety dictates otherwise. Such situations also need to be trained.

Emergency checklists are essential tools that flight crews use to respond to serious and time-critical situations. The lists must be well designed and clear; and adherence to these lists must be trained.

SOPs for communication between pilots on approach frequently give no special authority for the pilot not flying to command a go-around, and this is of particular concern when the pilot not flying, is the more junior crew member. It is recommended that operators devise and implement Policies to allow the “Emergency authority” for pilots not in command to take control in emergency situation, should be encouraged and enforced.

Most terrain awareness systems currently available are incompatible with VFR operations in mountainous terrain.

Nuisance’ warnings have the potential to exacerbate CFIT risk. The crew members should be advised not to isolate audio warnings.  It is recommended that regulatory authorities and operators interact with system manufacturers to review the warning logic to ensure that the frequency of nuisance warnings is minimized, without unduly compromising the systems terrain awareness and warning capabilities.

‘Nuisance’ warnings can also be inherent in the design of approach procedures, especially those using satellite based guidance to provide instrument approaches in challenging terrain.

Safety Management System (SMS), enhanced CRM, strict adherence to SOPs and result oriented Ground training need continued emphasis.

Unclear approach templates may cause pilots to deviate from them or misinterpret them hence taking them close to unsafe areas especially if the airport is near mountainous regions. This is exacerbated especially if pilots are unfamiliar and are operating into the airport in a night time environment. Operators and pilots must ensure that they carry the most up-to-date flight instrument charts so that they fly the correct instrument charts and do not fly into terrain mistakenly.

An unstable approach also has been found to be a factor contributing to CFIT accidents. Unstable approaches increase the possibility of diverting a flight crew’s attention away from the approach procedure to regain better control of the airplane. Operators must require their pilots to fly a stabilized approach and to always make timely decision to go-around from an unstable approach.

It is evident that most of the CFIT accidents result from a pilot’s breakdown in situational awareness (SA) instead of aircraft malfunction or a fire. SA refers to the accurate perception by flight crew of the factors and conditions currently affecting the safe operation of the aircraft, and their vertical and/or horizontal position awareness in relation to the ground, water, or obstacles. The data shows that 49 percent of CFIT accidents had vertical, lateral or speed deviations as a contributing factor to CFIT accidents.

Situational awareness can be enhanced through proper flight planning, preparation, knowledge about aircraft, systems, on board equipment, procedures, alertness and vigilance particularly during critical phases of the flight and good CRM. More reliable warnings of possible terrain conflicts through EGPWS that is equipped with accurate navigation systems like global positioning system (GPS) for both navigation and terrain surveillance can improve situational awareness.

Flight crew non-compliance with established procedures was a contributing factor in 23 percent of CFIT accidents. Poor CRM was also a frequent contributing factor.

Pilot Performance remains a major factor in CFIT accidents; despite the efforts to mitigate risk, handling and/or inappropriate actions by flight crew continue to be weak area..

Training, whether it is academic or simulator training, should allow pilots to experience realistic situations that require timely decisions and correct responses. Simulator training should also be given to provide pilots the opportunity to practice CFIT prevention strategies, including the escape manoeuvring. Training should be given to pilots during initial, transition and recurrent training.

Data collection and analysis can provide information of threats, hazards and identify potential weaknesses of an operator.

Collection and sharing of flight data in order to identify hazards ahead of time and mitigate those risks that can lead to an accident is another important element for continued improvement in CFIT accidents.

The best potential source of operational data is the operators’ own Flight Data Monitoring (FDM), Flight Data Analysis (FDA), or Flight Operations Quality Assurance (FOQA) programs.

The aim should be to improve safety through an analysis of information downloaded from an aircraft’s on-board computer at the end of every flight. This information can be used to identify trends and discover issues that might develop into a serious safety problem.

The routine download and analysis of recorded flight data has been used by operators for many years as a tool to identify potential hazards in flight operations, evaluate the operational environment, validate operating criteria, set and measure safety performance targets, monitor SOP compliance and measure training effectiveness.

In non-routine circumstances, when an incident occurs the data can be used to debrief the pilots involved and inform management. In a de-identified format the incident data can also be used to reinforce training programs, raising awareness amongst the pilot group as a whole.

Revise the minimum operational performance standards to improve the effectiveness of terrain awareness and warning systems when an airplane is configured for landing and near the airport, including when the airplane is descending at a high rate and there is rising terrain near the airport. 

All operators of airplanes equipped with the automated “minimums” alert should brief crew members to activate it.

For those airplanes not equipped with an automated “minimums” alert, it is advised that all operators of airplanes equipped with terrain awareness and warning systems (TAWS) to activate the TAWS 500-ft voice callout or similar alert. 

Human, Procedural, Technological. The available human mitigations involve improving and maintaining pilots’ knowledge, their awareness and their competence, and each of these can be achieved by a comprehensive training program embracing classroom, simulator and flight training.

With realistic training, flight crew will be well prepared to:

Know the hazards of flying close to terrain.

Recognize the symptoms of spatial disorientation.

Recognize the factors that may lead to CFIT accidents.

Know the mitigation strategies that will ensure a safe flight.

 

The Safety management systems (SMS) must incorporate management procedures to constantly review and assess the CFIT risk exposure to the operation in order to ensure that the risk is as low as reasonably practicable (ALARP) and tolerable.

Technologies have also been developed to mitigate the risk of a CFIT accident. There are a variety of technologies available but the most considerable one is TAWS/EGPWS; this technology can be used with a terrain map database via GPS to provide the pilots with a more reliable source of data.

Unfortunately, many pilots falsely believe that there is sufficient time to react once an EGPWS alert is sounded. In order to be effective, it is essential that the aircraft system hardware and firmware are correctly maintained and that the software database is properly updated.

Vertical situation displays in the cockpit are becoming more common and these provide pilots with an easy to assimilate picture of the terrain profile ahead of the aircraft, together with its projected vertical flight path.

Operators must ensure that the latest modifications are incorporated in their TAWS/EGPWS computer and with GPS providing aircraft position data directly to the computer. These provide earlier warning times and minimize unwanted alerts and warnings.

Furthermore, appropriate TAWS/EGPWS response procedures by the operators should be established for the flight crew in accordance to the aircraft type performance capability. These procedures should include and encourage pilots that “warnings” should be followed without hesitation as soon as a triggered.

DGCA should promote development and use of a low cost terrain clearance and/or a look ahead devices particularly for helicopters who operate at low levels close to the terrain, obstructions.

Supervision and monitoring of flying operations by Accountable Managers, Chief Operations Officers, Chief Pilots  of aircraft and helicopters particularly  belonging to NSOP, State Govt and Private operator’s needs to be improved.

Effective implementation of SMS which improve Company Safety culture, must be ensured.

The senior management, Accountable Managers, Chief Operating Officers and Chief Pilots must proactively identify hazards related to operations during adverse weather conditions (Pre Monsoon, Summer Season, Monsoon Season, Winter Season) and operations to and from airports, helipads which are known to be difficult and challenging. Standard procedures should be introduced to brief the pilots about the hazards and precautions they need to take to operate safely. Operations Staff and Chief of Flight Safety should be fully involved and remain extra alert and vigilant during marginal weather conditions to provide necessary and accurate weather related information, support and guidance to pilots.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Delhi: With the domestic flights resuming operations from Monday, the Central government on Sunday decided to restart regional air connectivity services under the UDAN scheme on select routes and with conditions. The central government said that the services will be started as per the modalities set by the Ministry of Civil Aviation.
Issuing an order, the Central government said that all the operational routes in priority areas which include the northeastern region, hill states and islands are permitted to resume operations.
The order further stated that all operational helicopter routes are permitted to resume operations. All operational routes with no viability gap funding (VGF) are permitted as well. Also Read – Heartbreaking Pictures Show Lions Starving In Sudan Zoo, Spark Online Campaign to Save Them.
The Ministry of Civil Aviation said that all operational routes up to 500 km stage length are permitted to resume operations. “And selected airline operators (SAOs) are allowed to operationalise awarded routes under UDAN, including seaplanes on the permitted routes,” it said.
“If willing to operate without VGF support, SAOs may operate Tourism RCS routes (T-RCS) or RCS routes with stage length more than 500 km in areas other than Priority Areas. However, other incentives for the respective routes as per the scheme document would continue to be available for the contract period,” the order said.

Amphan damages aircraft and two hangars

Structures that collapsed were unauthorised: Airport director

At least two hangars of Air India at the Calcutta airport collapsed, one plane was smashed and portions of the terminal’s roof were blown away during Wednesday’s storm.

Airport officials said hangars 16 and 17 collapsed because of the cyclone and a four-seater Cessna aircraft, which was parked in hangar 16, was damaged after the structure crashed on it.

A 42 seater ATR- 42, which was parked inside hangar 17, was brought out by the airline authorities and parked outside, just as many Calcutta’s were taking out their cars from flooded garages.

“That was the reason why the aircraft did not suffer any damage even though hangar 17 had collapsed,” an airport official said.

However, the nose of the aircraft turned 180 degrees because of the strong winds, the official said.

“The two hangars that collapsed were more than 50 years old and owned by Air India. We had asked them to remove the hangars several times because those were unauthorised constructions but they have not done so,” said airport director Kaushik Bhattacharya.

“The aircraft that got damaged was parked by a private aviation company. For the last two years we have been asking the company in vain to remove the aircraft.”

Air India officials could not be reached. Phones of at least two officials were unavailable through the day.

Bigger aircraft are parked on the tarmac in the open. Officials said that earlier 52 aircraft used to be parked at the airport overnight. Now, the count has come down to 42 because of the lockdown.

In several parts of the terminal, roof made of corrugated sheets was blown away.

Officials said the roof had three layers of corrugated sheet and insulation. As the top layer was removed, there was a huge amount of water seepage, flooding parts of the terminal.

“The roof will be repaired quickly,” said the airport director.

Portions of the airport’s tarmac were flooded. “The main inundation was on the Kaikhali side. We were trying to pump the water out but were unable to do so because the adjoining areas were waterlogged,” the airport director said.

The airport was closed till 5am on Thursday. An official said the airport finally became operational at noon with the take-off of a Spice jet flight to Delhi.

A flight from Russia had arrived at 2.30 on Thursday to evacuate 103 Russian nationals who were stuck because of the lockdown.

According to airport sources there was a delay in starting flight operations because several branches of trees had fallen on the tarmac and portions of the runaway, which needed to be cleaned.

 

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Bengaluru airport voted as best regional airport in India & Central Asia

BENGALURU: Bengaluru’s Kempegowda International Airport  was voted by customers as the best regional airport in India & Central Asia for the third time in four years at the 2020 World Airport Awards.

For an 11-year old airport, it’s a remarkable achievement, said MD and CEO of BIAL (Bangalore International Airport Limited), Hari K Marar.

“This award reaffirms our commitment to provide a world-class experience for our travelers at BLR Airport with a slew of pioneering technology and sustainability initiatives,” he was quoted as saying in a BIAL statement.

According to the statement, the World Airport Awards are the most prestigious accolades for the airport industry,

“At a time like this, when our industry is facing such challenges, this award has rejuvenated the morale of the team at BLR Airport,” Marar added.

According to the statement, the World Airport Awards are the most prestigious accolades for the airport industry, voted by customers in the largest, annual global airport customer satisfaction survey.

They are regarded as the quality benchmark for the world airport industry, assessing customer service and facilities across over 550 airports.

Safety Aspects-Commencement of Domestic Flight Operations

 

The much awaited news about the commencement of Domestic Flight Operations wef 25 May, after a long break, is a welcome development. The officials from MOCA, DGCA AAI and BCAS must have worked very hard notwithstanding the trying conditions created by COVID 19, to prepare and introduce various guidelines, rules and regulations to facilitate the commencement of the flight operations with safety and efficiency. It is a herculean and highly challenging task and the dedicated efforts of the Officials from all these departments, under unprecedented situation, are worthy of high praise.

The main concern of ASMSI is related to the Safety of the Domestic Flight Operations and we are sure that the concerned regulatory authorities and airlines must have given serious thought to safety aspects of operations.

The flying is commencing after a long break and the parked aircraft in the open skies must have been subjected to high temperatures, dust and water accumulation during thunder/ dust storms. This may have deteriorated or adversely affected the condition and performance of sensitive electronic equipment on board the aircraft, including alarm/warning systems and rubber seals etc.

Possibility of the rodents and reptiles entering some aircraft and birds, honey bees making nest/beehive on the aircraft, is another area of concern.

The adverse effect of parking of the aircraft for a long time may also lead to degradation of the material of tyres in contact with the surface and merits attention.

Aircraft with more than 20 years of life should be given special attention during inspection, maintenance, repairs and supervisors must be always very alert and vigilant to keep a close eye on the maintenance activities to ensure that there are no lapses.

The Flying, Maintenance and Air Traffic Controlling related currency  and recency aspect of the Pilots, Cabin crew, Engineers, Technicians, ,ATC staff, Dispatchers,Ops and Maintenance Staff, Ground Handlers, Drivers of the Airside vehicles etc. should attract the attention of the management of the airlines. Special emphasis should be laid on refreshing the skill and   knowledge levels of all these personnel lest the safety gets compromised.

The Pilots, Cabin Crew will be undertaking their task clad in PPE which may lead to restriction on the movement of their body parts to certain extent. Crew members need to be aware about the possibility of the distortions/inadequacy in communication due to PPE, Mask etc.

Cabin crew will have an important role to play in ensuring social distancing, use of masks, sanitisation and comforting the passengers. Some passengers becoming unruly due to psychological impacts of CORONA during the flight is a distinct possibility and may be factored by the airlines during the briefing.

Now onwards till September, the flying will be undertaken in very high temperature and active Pre monsoon/Monsoon conditions, with attendant risk related to this season. Pilots need to brush up their knowledge about their Aircraft,Systems,Avionics,Nav Aids,Radar,SOP’s,Procedures,Emergencies,Spatial Disorientation, Illusions, CFIT,Situational Awareness, Wind Shear, Hydroplaning and effect of high temperatures on performance.

In the interest of the Safety of the Operations, it would be essential to ensure dedicated involvement of the Top Management of the Airline and Airports, particularly Accountable Executives, Head of Safety,Operations,Maintenance and Training.

Thorough Pre Flight Briefing, Pre Descent and Approach briefing, Passenger briefing, Operation Risk Management, good CRM, Situational awareness and sound Decision Making are key to safe and efficient conduct of operations.

All the Operators are experiencing financial stress and may get in a great hurry to generate revenue and make up their losses. The tendency and temptation to take shortcuts in Operations, Maintenance and other related areas, compromise in compliance of rules, regulations and SOP’s etc. can be a serious hazards to safety. It is expected that all the stakeholders will adhere to the rules, regulations and will certainly involve themselves to measure up to the expectations of the Regulatory Authorities.

It has to be kept in mind that the Air, Ground, ATC Crew and supporting staff will be operating during adverse weather conditions experienced during extreme Summer, Pre monsoon and Monsoon months and they will be under great pressure to undertake the flights so as to generate revenue for the Company. Pilots, Engineers and other personnel operating under pressure conditions may pose major flight safety hazard and it needs to be addressed.

Further, the Air Crew as well as Ground and ATC crew will be operating under tough conditions due to lack of adequate suitable transportation,boarding,lodging facilities ,deduction in pay and allowances, perks and concern about their own and their family health. Psychological and fatigue factor of these personnel must be addressed and strict adherence to FDTL and FTL need to be ensured.

Due to disruption in manufacturing and supplies all around the world and massive orders backlog, the availability of spares and critical equipment will be a cause of great concern. So the Operators need to plan well in advance and should not pressurise Pilots and Engineers to make compromises on the airworthiness of the aircraft.

The Operators need to strike a healthy balance between Economic Revival, Viability and Safety of operations. Safety first and Safety Always should remain the motto if we are to make successful revival and economic viability.

It is also recommended that all the Operators conduct internal safety audit of their Ops,Training,Safety and Maintenance departments keeping the above aspects in mind, identify hazards in a Proactive manner and take prompt remedial measures.

Accountable Executives of the Operators should be impressed upon to fully involve themselves in ensuring high standards of safety in their respective organisations.

We are conscious of the fact that the Aviation Professionals from DGCA and Operators are highly knowledgeable and must be fully involved and already working on the lines which have been covered above.

Aviation Safety India will be more than willing to assist the Regulator and the Operators towards spread of knowledge and awareness, in conduct of audits and enhancing safety of Aviation Operations.

 

 

Proactive Hazard Identification, Reporting Hazards, Addressing and Eliminating Hazards are Key to Safe Conduct of Operations.

 

From mandated social distancing, to thermal scans and potentially higher fares, your journey is likely to get a whole lot more cumbersome.

KEY HIGHLIGHTS

The Offshore Helicopter Pilot’s Operating

Environment

Offshore flight operations are highly complex and specialised processes. It requires high levels of training, competence and skill to plan a flight, to land and take off from an offshore installation and to consistently execute the task safely and efficiently under ‘normal’, good weather flying conditions. When a task is carried out in adverse weather (e.g. poor visibility), during night flying and when other predictable and/or unpredictable factors routinely found in and around the environs of an offshore installation or vessel, the skills of flight crews can be stretched. Unlike pilots operating from onshore airfields, offshore helicopter crews have relatively little ground-based technology and fairly limited information to assist them as they commence their final approach for landing on an offshore helideck.It is much the same when taking off.

 

Despite the many advances in aircraft technology, navigation, landing and communications aids in recent years, there are currently no reliable and effective electronic landing aids available for use on offshore installations / vessels. Therefore, offshore helicopter crews have to rely heavily on their acquired skills and experience when approaching, landing and taking off from offshore

installations / vessels. It is not necessary or appropriate to review the whole scope of helicopter flying in these guidelines. However, it is essential to consider two important topics concerning flight crew activities performed within the offshore flight operations process. These two topics are:

(1) Pilot information.

(2) Approach, landing and take-off manoeuvres.

Aircraft Selection

During the contracting process selection of aircraft types for offshore support operations may appear to be a matter of customer choice but ultimately, it will depend on the composition of the aircraft operator’s fleet, type availability and duration of contract. A key economic consideration from the offshore oil and gas company perspective is to maximise aircraft payloads and thus avoid the high cost of wasted aircraft capacity. Helicopter operators can help to achieve this through aircraft selection; however to do this properly, oil and gas companies will need to provide prospective helicopter operators with a detailed and accurate forecast of aircraft utilisation throughout the contract term. In addition, they should contractually ensure that day to day aircraft utilisation is monitored and implemented to secure the most cost efficient helicopter service.

 

Long term contracts allow a helicopter operator to better meet customer demand particularly if new airframe types are the preferred option. When specifying helicopters for offshore helicopter support operations oil and gas companies should ensure that they are properly equipped for the type of operations to be undertaken. Offshore oil and gas companies should consider the above factors during the Invitation to Tender phase.

 

Minimum Equipment List (MEL)

Flight crews and maintenance personnel must always have available for reference an approved aircraft Minimum Equipment List (MEL) for the appropriate aircraft type.

 

 

 

Maintenance Requirements

All aircraft maintenance shall be carried out in accordance with the approved manufacturers’ instructions, service bulletins, airworthiness directives and inspection / replacement schedules as officially issued and amended from time to time.

Quality Assurance

A key element of an effective SMS is the existence and application of a suitable Quality Assurance (QA) System that includes an internal audit program that is managed at the local operational level, and is subject to periodic management review. An air operator’s Quality Assurance system should cover the operations, maintenance and support organisations. The key elements of such a system should include the appointment of a Quality Manager, procedures for the operation of the system, an audit plan, record of audit findings, evidence of follow-up and close-out of findings, and an executive review process.

 

Aircraft Operator Auditing

An aircraft operators should be reviewed on a regular basis, at a frequency determined by risk, exposure, usage and performance of the air operation on the previous review. There is a distinct difference between commercial and technical / operational auditing. These guidelines do not cover commercial auditing so the following sections relate only to aviation flight, technical and support operations audits. Oil and gas companies should recall that offshore helicopter operators are highly regulated and are audited annually by the regulator/ or third competent party across their entire operation. Therefore, the frequency, style and manner in which customer flight, technical and support operations audits are conducted at the aircraft operator’s facility should be properly considered. The required audit frequency and reporting value to the oil and gas company / duty holder to assure proper management overview, due diligence and contractor compliance should be fully considered; along with the potential for creating significant interference with the aircraft operator’s day to day operations.

 

Aviation Auditing Principles

Aircraft operator flight, technical and support operations audits are required by oil and gas companies in order to determine initial suitability and capability for providing a safe offshore helicopter service and thereafter to assess ongoing contractual compliance and, where appropriate, to make recommendations for improvements. Aviation flight, technical and support operations auditing is a specialist area that requires trained and competent auditors and often, these individuals are not normally retained members of oil and gas company staff so they have to be outsourced.

 

Coordination of Audits

Audit visits must be planned in close co-operation with the aircraft operators and managed appropriately to reduce the impact that the potentially large number of audits can have on the helicopter company day-to-day operations. Where several companies use the same helicopter operator, consideration should be given to a ‘joint audit’ with a single audit team representation. Alternatively, oil and gas companies are encouraged to co-operate in a pooling arrangement for auditing that would see agreed periods where several aircraft company customers audit the aircraft operator at the same time but with their own audit teams.

 

 

 

Audit Frequency

The planned frequency at which audits are carried out by oil and gas companies is generally dependant on contractual requirements. Normally, these audits will be conducted on an annual or biennial basis. The oil and gas company initiates the audit process, with suitable advance notice, by arranging direct with the helicopter operators. Usually, a minimum of three months is required for scheduling audits. Audits shall be arranged at realistic intervals to minimise the operational impact on the helicopter operators. It should be noted that the average audit could take several people several man days for the aircraft operator to complete the whole process. This includes planning, time spent on pre-audit questionnaires, the audit itself at aircraft company head office and the operating base(s), the time needed with each nominated post holder and the time taken by the safety and quality representatives that accompany the audit team.

 

Minimum Auditor Qualification Standards

Personnel undertaking aviation flight, technical and support operations audits should be aeronautically trained and hold appropriate qualifications accompanied by several years’ relevant experience. Ideally, they should also have completed a recognised auditor’s course provided internally by the oil and gas company or by an organisation which is approved to supply auditor training to the International

 

Aviation auditors should also:

􀁸 keep their understanding of aviation systems, standards and audit procedures current and accurate;

􀁸 be able to properly collect information, evaluate evidence, make observations and draw together well founded conclusions;

􀁸 have at least four years’ of relevant aviation audit work experience;

􀁸 keep an open mind and fully understand that there are often many alternative means of compliance;

􀁸 be prepared to provide experience based practical suggestions / solutions to identified problems (if requested or challenged).

 

Auditor Independence and Credibility

Impartiality and objectivity of auditors are basic pre-requisites for an effective and consistent audit. A good audit will benefit both the auditor and the organization being audited by obtaining mutual agreement for ways to refine and improve the overall operation. The main principles for inspiring confidence are independence, impartiality and competence both in action and appearance. Training in audit and knowledge of the processes will ensure that an individual is competent to audit. However, since effective audit requires the full co-operation of the organisation being audited, the auditor must be credible. Individuals of sufficient authority and maturity who are not too closely associated with the organisation being audited should therefore be selected. Safeguards that mitigate or eliminate threats to auditor impartiality and therefore protect the interests of both parties should be introduced.

Auditors should not have:-

􀁸 a financial interest in the aircraft operator being audited;

􀁸 an emotional interest in the aircraft operator being audited i.e. if a relationship exists between auditor’s family members and an aircraft operator employee;

􀁸 been employed, in the previous 2 years, by the aircraft operator subject to audit;

􀁸 a particularly close or long-standing personal or professional relationship with the aircraft operator being audited;

In order to ensure independence, auditors shall not audit any processes they are directly involved in. Auditors must maintain an objective state of mind throughout the audit process to ensure that the audit findings and conclusions are only evidence based.

 

Developing Competence through Training

Identifying Competencies for Each Role

A Functional map should be developed summarizing the main functions and responsibilities which helideck crew would be expected to fulfill. Competence statements should be derived from the functional map. These statements describe the skills and knowledge necessary to perform the role of an HLO or an HDA.

 

Training the Individual to Achieve the Required Competence

The OPITO training programme contains full details of the onshore training requirements for each category of personnel, along with entry criteria, training outcomes, training programmes, practical exercises and further practice. It also sets out standards of qualification and experience for training assessment staff, instructor / delegate ratios, and specifications for training equipment, and facilities and details of training provider responsibilities.

 

Offshore Helicopter Operations Management

 

Irrespective of the specific operating purpose of the offshore installation or vessel or the frequency and extent of day-to-day helicopter operations, the same fundamental requirements for the receipt and dispatch of helicopters will apply. Nowadays, personnel involved in helideck operations have other primary duties and are not members of a full-time helideck crew. Therefore, special consideration should be given to the operating practices, procedures and continuing competence of the helideck crew. Irrespective of the frequency and volume of helicopter traffic, the level of preparedness and effectiveness of both personnel and equipment involved in helicopter operations needs to be to a single satisfactory standard. On facilities with infrequent helicopter operations, this may involve a significant commitment to ensure there are enough adequately trained personnel available for helideck duty. Such operations will require routine monitoring and testing to ensure proper standards are maintained.

 

Step Change in Safety – First-time Travelers

Checking in and flying offshore in a helicopter is invariably a bewildering and sometimes worrying experience for the first-time or infrequent traveler. Therefore, duty holders are encouraged to adopt appropriate procedures to identify and assist inexperienced individuals when they travel offshore in a helicopter, particularly for the first time. operators but the objectives should be the same and similar fundamental processes followed (e.g. a green armband policy).

 

Initial Identification of First-time Travelers

Prior to arriving at the heliport, all first-time travelers should be identified by the duty holder and employing companies (e.g. contractors, vendors and visitors). Ideally, this information should be readily available on the flight booking system at the heliport check-in desk (e.g. Vantage). In addition, attention should be drawn to the requirement that it is the individual’s responsibility to notify the check-in desk if they are a first-time or infrequent traveler.

Green Armband Policy

At the check-in desk, a first-time traveler to an installation or an infrequent visitor (more than 12 months since last flight) should be issued with a green armband and be given clear instructions to wear it in a visible location on the sleeve of the survival suit. Also, the individual should be advised that by wearing the armband they are easily identifiable to fellow passengers, the flight crew, heliport ground staff and helideck crews who can then ensure they are escorted and assisted throughout preparation and during their journey offshore.

 

 

Communications to Improve Workforce Confidence in the Safety of Helicopter Operations

Following the fatal accidents at Morecambe Bay in 2006 and during a return flight to Aberdeen in 2009 it became essential for industry to respond to workforce concerns and provide practical solutions for improving the confidence of passengers flying offshore. Solutions that are available include:

􀁸 Helicopter Operations Awareness Courses for safety representatives with a set syllabus provided by the helicopter operators that includes presentations to demonstrate the rigor and professionalism of the maintenance and operational controls, together with a tour of the operating base and other fixed elements.

􀁸 A DVD that covers similar elements with the addition of a Q & A where various individuals ask questions and to receive answers from specialists.

 

Providing Helideck Operating and Performance

Information for Flight Crews

 

Flight Planning Information

Helicopter flight crews have a vital need for accurate knowledge of the details of the helideck, available support facilities and surrounding operating environment. Therefore, installation operators and vessel owners should always provide with current drawings, specifications and relevant design reports (e.g. helideck model testing) for new or modified topsides and helidecks where the design and / or modifications have potential to degrade airflow characteristics at the helideck.

 

Flight Management Information

To enable flight crews to manage an offshore flight safely, an essential ingredient in the operational information flow is for them to receive accurate and up-to-date weather and installation / vessel operations data (e.g. vessel motions, number of gas turbines online, etc). Flight crew confidence in the quality of the information obtained onshore, transmitted from the installation / vessel whilst en route and at the destination helideck will be a key factor toward ensuring the flight proceeds safely and as planned.

 

Installation Identification

To avoid confusing helicopter flight crews and to reduce the potential for wrong deck landings, particularly where several installations of similar appearance and/or belonging to the same duty holder are in close proximity, it is essential to ensure that the installation identification boards, the helideck identification marking (i.e. the name) and the radio call sign are consistent. Refer CAP437.

Installation and vessel visual identifications should at all times be kept un-obscured, in clean condition and well illuminated at night or when there is limited visibility. It is also recommended that duty holders adopt a procedure whereby helicopters approaching to land on an offshore helideck are visually identified by the HLO and the correct helideck destination is confirmed verbally with the flight crew.

 

Installation / Helideck Safety Status Signals

 

Status Lights Protocol and Procedures

Installations and vessels (when appropriate to the type of operations being undertaken) should be equipped with a helideck status light system specified in accordance with Civil Aviation Publication (CAP) 437  or ICAO Annexure 14 Volume II..

 

Meteorology and Adverse Weather Procedures

 

Meteorology

A key component of aviation safety and flight planning is the acquisition and use of accurate weather information. Helicopter operators routinely obtain their regional and area weather forecasts and ‘actuals’ for flight planning purposes from official Met Office sources. However, an essential part of the management of offshore helicopter operations is to provide the helicopter operator and flight crews with up-to-date and accurate weather information for the destination installation or vessel. When providing destination weather information for an offshore installation and  vessel, onshore and offshore management should ensure that the necessary instrumentation is available (properly calibrated) and a competent person employed to make comprehensive and accurate meteorological observations and readings. The information should be recorded and then transmitted to the helicopter operators and / or flight crews in the correct format with the time of the observations clearly stated. It is worth noting that should a meteorological reading be in doubt due to instrument calibration or other problem, a gross error check can be made by cross-checking with other rigs and vessels in the immediate area. The ‘agreed’ best practice for met recording, reporting and met observer training and competence can be found in CAP437, Chapter 6, The safety of helicopter operations to moving helidecks on floating structures and vessels is also dependent on flight crews receiving accurate information about helideck motions.

 

it is strongly recommended that installations are provided with an automated means of ascertaining the following meteorological information at all times:

1. a) Wind speed and direction (including variations in direction);
2. b) Air temperature and dew point temperature;
3. c) QNH and, where applicable, QFE;
4. d) Cloud amount and height of base (Above Mean Sea Level (AMSL));
5. e) Visibility; and
6. f) Present weather.

 

Pre-Flight Weather Reports

The latest weather report from each installation should be made available to the helicopter operator one hour before take-off. These reports should contain:

• The name and location of the installation;
• The date and time the observation was made;
• Wind speed and direction;
• Visibility;
• Present weather (including presence of lightning);
• Cloud amount and height of base;
• Temperature and dew point;
• QNH and QFE;
• SHR;
• Pitch and roll; and

.

Adverse Weather Operations

They cannot be avoided. Therefore, access to up-to-date and accurate weather forecasting information is essential to allow advance planning of helicopter operations to take place.

The onset of adverse weather conditions offshore introduces a number of related factors that must be considered and closely examined by a duty holder’s operations management (on and offshore) in order to make prudent judgments as to whether routine offshore helicopter flights should continue, be delayed or curtailed altogether.

Note: Routine is defined as all flights with the exception of those for casualty evacuation, platform evacuation and marine Search and Rescue (SAR).

 

Control of Crane Movement in the Vicinity of Landing Areas

Cranes can adversely distract pilots’ attention during helicopter approach and take-off from the helideck as well as infringe fixed obstacle protected surfaces. Therefore it is essential that when helicopter movements take place (±5 minutes) crane work ceases and jibs, ‘A’ frames, etc. are positioned clear of the obstacle protected surfaces and flight paths. The HLO should be responsible for the control of cranes in preparation for and during helicopter operations.

 Emergency Response

In the event of an accident involving an offshore helicopter whether en-route or on or around an offshore installation, it should be understood by oil and gas duty holders that such an event will automatically involve the helicopter operator who, as the Air Operators’ Certificate (AOC) Holder has a legal responsibility to report an occurrence and have emergency response procedures in place under the Air Navigation Order (ANO).After the initial marine SAR emergency response, co-ordinated to recover casualties, AAIB will take the accident investigation lead as required under the Civil Aviation (Investigation of Air Accidents and Incidents) Regulations The helicopter operator along with the helicopter manufacturer will become the primary focus for the AAIB Investigation whilst  regulating authority  will retain an oversight.

 

With offshore helicopter accidents, the above relationships are not readily recognised or acknowledged by media organisations so they will probably focus their immediate attention on the oil and gas operating company. When oil and gas operating companies are planning emergency responses that involve offshore helicopters it is therefore imperative there are well defined procedures in place to accommodate the interfaces with the helicopter operator to look after mutual interests and concerns.

􀁸 Protecting persons on the installation from fire and explosion

􀁸 Securing an effective emergency response offshore installation.

 

Emergency Response Planning

Airborne emergencies on offshore helicopters that result in a catastrophic fatal crash occur rarely. Unfortunately when they do happen, they instantaneously become the intensive and incessant focus of attention by the news media organisations – they are also global and this has a huge impact on crisis management for the oil and gas operating company, its contractors and the helicopter operators.

 

Passenger Management

To ensure the safety and comfort of all passengers travelling on offshore helicopters, it is essential that sound and consistent controls be employed.

 

Passenger Briefings

The helicopter operator is legally responsible for ensuring that prior to the departure of any flight all personnel travelling are given a thorough briefing on the safety instructions and emergency procedures for the type of aircraft to be flown and safety equipment in use. Where the flight involves travelling over water, all passengers should be given a comprehensive briefing on the survival suit and lifejackets to be worn, underwater Emergency Breathing System (EBS) and PLBs. A short, final departure brief should be given to passengers prior to boarding the flight The manner in which these briefings are accomplished offshore is the responsibility of the installation Operator, MODU or vessel owner.

 

Arrangements

Every aircraft operator is required by law to place flight safety information cards onboard an aircraft designed to carry passengers. These are usually placed in the seat pockets to allow free access for all passengers to study. Similarly, flight attendants, when they are carried, give a visual and verbal flight safety briefing to the passengers. Flight attendants are not normally carried onboard offshore helicopters.

 

Also, more comprehensive passenger briefings are required for travelers to offshore installations and vessels. The briefings are normally provided in video form in the ‘suiting-up area’ at the heliport and the offshore location. Generally, offshore installations, and vessels will provide a suitable area where passengers are shown a helicopter operator approved video briefing of the aircraft type including safety and emergency procedures and lifejacket operating instructions. Additional video briefing material covering procedures for the wearing of survival suits and using PLB and EBS devices will also be provided by the installation operator, or vessel owner. The video method is preferable to a verbal briefing. When updates and amendments to any briefings come into force, they should be made available, as soon as practicable, at all locations holding such briefing material.

 

Passenger Manifests

Correct manifesting by the onshore helicopter company staff and HLO of passengers, baggage and freight is essential to enable the flight crew to calculate the total weight accurately on the aircraft load sheet. Inaccurate weights on the manifest can result in adverse aircraft performance and centre of gravity limits being exceeded.

Note: The HLO should ensure that correct units of weight (e.g. lbs or kg) are used in accordance with the helicopter operators’ requirements. Incorrect use of units of weight can have a major impact on the safety of an aircraft. Manifests should be prepared in a legible fashion and sufficient copies provided for retention of records for every sector of the aircraft flight. They may be computer or manually generated.  For security reasons, all manifests should show the number of bags per passenger.

 

Passenger Baggage Weight Limits and Labelling

Offshore passenger baggage should not exceed 25 lbs (11.3 kg) per individual and should be contained in a properly secured, robust, soft-walled holdall. Baggage exceeding the weight limit or contained in large, hard-walled cases or cabin trunks should be despatched by an alternative shipping method. Baggage should be labelled with the correct destination on all flights. Such labels should be ‘airline type’ ensuring maximum integrity. Where a duty holder authorises (at the embarkation point) an individual’s passenger baggage limit to exceed 15 kg or the article is a large hard-walled case or cabin trunk, the helicopter crew and receiving location should be notified.

 

Helicopter Operations Support Equipment

Provision should be made for equipment needed for use in connection with helicopter operations including:

1. a) chocks and tie-down strops/ropes (strops are preferable);
2. b) heavy-duty, calibrated, accurate scales for passenger baggage and freight weighing;
3. c) a suitable power source for starting helicopters if helicopter shut-down is seen as

an operational requirement; and

1. d) equipment for clearing the helicopter landing area of snow and ice and other contaminants.Chocks should be compatible with helicopter undercarriage/wheel configurations.

Helicopter operating experience offshore has shown that the most effective chock for use on helidecks is the ‘NATO sandbag’ type. Alternatively, ‘rubber triangular’ or ‘single piece fore and aft’ type chocks may be used as long as they are suited to all helicopters likely to operate to the helideck. The ‘rubber triangular’ chock is generally only effective on decks without nets. For securing helicopters to the helideck it is recommended that adjustable tie-down strops are used in preference to ropes. Specifications for tie-downs should be agreed with the helicopter operators.

SITUATIONAL AWARENESS

Build Situational Awareness:

Set specific objectives – Define flight targets and data gathering.

Set priorities – Follow standard operating procedures (SOPs).

Prepare for anomalies – Consider visual illusions, missing information, etc.

Make risk assessments – Ask “what if?”

Manage workload – Shift tasks away from busy times, delegate, anticipate.

Maintain Situational Awareness

Communicate – Keep all crew members and external participants informed.

Manage attention – Set priorities, avoid distractions, adjust monitoring to the urgency of the flight phase

Seek Information – Use your senses.

Know WHAT is important, WHEN to seek it and WHERE to find it 9Validate your data.

Cross-check – Use multiple sources of information when available.

Use rules of thumb when data are not available

Check Your Understanding.

Check for contradictory elements in the real world 9Apply experience and lessons learned.

Think Ahead

Brief others on what you expect.

Compare projected situation with objectives.

Set markers for confirmation and information.

Compare actual situation with expectations and objectives.

Readjust your plan if required.

Detect Loss of Situational Awareness

Ambiguity – Unclear flight plans or ATC instructions

Fixation – Focusing on one thing to the exclusion of all else

Confusion – Uncertainty about or misunderstanding a situation or information.

Preoccupation – Everyone focusing on non-flying activities; no one flying the aircraft.

Unresolved discrepancies – Contradictory data or personal conflicts.

Expected checkpoints not met – Flight plan, profile, time, fuel burn.

Poor communications – Vague or incomplete statements.

Broken rules – Limitations, minimums, regulatory requirements, failure to follow SOPs.

No time – Falling behind the aircraft

Recover Situational Awareness

Go to the nearest SAFE, SIMPLE and STABLE situation

Follow rules, procedures and SOPs 9Change automation level.

Buy time.

Communicate

Asking for help is not a sign of weakness.

Recover the big picture.

Go back to the last thing you were sure of.

Assess the situation from different perspectives, with different sources.

Expand your focus to avoid fixation and tunnel vision.

Manage stress and distraction.

Take time to think / Use that time / Be willing to delay flight progress

QUALITIES OF ACCOUNTABLE EXECUTIVE, CEO

 

Mindful of Danger. .

Top managers are ever-mindful of the human and organizational factors that can endanger their operations.

Acceptance of Setbacks.

Top management accepts occasional setbacks and nasty surprises as inevitable. It anticipates that employees will make errors and trains them to detect errors and recover.

Commitment

Top managers are genuinely committed to aviation safety and provide adequate resources to serve this end.

Regular Meetings

Safety-related issues are considered at high-level meetings on a regular basis, not just after a bad event.

Events Reviewed

Past events are thoroughly reviewed at top-level meetings, and the lessons learned are implemented as companywide reforms, rather than local repairs.

Improved Defence.

After a mishap, the primary aim of top management is to identify the failed system defences and improve them rather than divert responsibility to particular individuals.

Health Checks

Top management adopts a proactive stance toward flight safety. It does the following:

• Takes steps to identify recurrent traps and remove them.
• Strives to eliminate the workplace and organizational factors likely to provoke errors.
• “Brainstorms” new scenarios of failure.
• Conducts regular “health checks” on the organizational processes known to contribute to mishaps.

Institutional Factors Recognised

Top management recognizes that error-provoking institutional factors (e.g., under-manning, inadequate equipment, inexperience, patchy training, bad human machine interfaces, etc.) are easier to manage and correct than fleeting psychological states such as distraction, inattention and forgetfulness.

Data

It is understood that the effective management of safety, just like other management processes, depends critically on the collection, analysis and dissemination of relevant information.

Sampling of ‘Vital Signs

Management recognises the necessity of combining reactive outcome data (i.e., near-miss and incident reporting) with active process information. The latter entails far more than occasional audits. It involves regular sampling of a variety of institutional parameters (e.g., scheduling, budgeting, procedures and training), identifying which “vital sign” is most in need of attention and then carrying out remedial action.

Employees Attend Safety Meetings

Meetings relating to flight safety are attended by employees from a wide variety of departments and levels.

 

 

Career Boost

Assignment to a safety-related function (quality or risk management) is seen as a fast-track appointment, not a dead end. Such functions are accorded appropriate status and salary.

Money vs. Safety

Safety Acknowledgment that commercial goals and safety issues can come into conflict. Measures are in place to recognize and resolve such conflicts in an effective and transparent manner.

Reporting Encouraged

Policies are in place to encourage everyone to raise safety-related issues. (One of the defining characteristics of a pathological culture is that messengers are “shot” and whistle-blowers dismissed or discredited.)

Trust

The company recognizes the critical dependence of a safety management system on the trust of the work force, particularly in regard to reporting systems. (A safe culture — that is, an informed culture — is the product of a reporting culture that, in turn, can only arise from a just culture.)

Qualified Indemnity

Policies relating to near-miss and incident-reporting systems make clear that the organization’s stance includes qualified indemnity against sanctions, confidentiality and the organizational separation of the data-collecting department from those involved in disciplinary proceedings.

Blame

Disciplinary policies are predicated on an agreed (i.e., negotiated) distinction between acceptable and unacceptable behaviour. All recognize that a small proportion of unsafe acts are indeed reckless and warrant sanctions, but the large majority of such acts should not attract punishment. (The key determinant of blameworthiness is not so much the act itself — error or violation — as the nature of the behaviour in which it is embedded. Did this behaviour involve deliberate and unwarranted risk-taking, or a course of action likely to produce avoidable errors? If so, then the act would be culpable regardless of whether it was an error or a violation.)

Non-Technical Skills

Line managers encourage their employees to acquire the mental (or non-technical) as well as the technical skills necessary to achieve safe and effective performance. (Mental skills include anticipating possible errors and rehearsing the appropriate recoveries. Such mental preparation at both the individual and organizational level is the one of the hallmarks of high-reliability systems, and goes beyond routine simulator checks.)

Feedback

The organization has in place rapid, useful and intelligible feedback channels to communicate the lessons learned from both the reactive and proactive safety information systems. Throughout, the emphasis is on generalizing these lessons to the system at large.

Acknowledgement of Error

The organization has the will and the resources to acknowledge its errors, to apologize for them and to reassure any victims that the lessons learned from such mishaps will help to prevent their recurrence.